Clay Marsh: Explaining West Virginia’s COVID Code

COVID-19 is a generational event that has caused the death of over 210,000 Americans and 1 million individuals worldwide.

Those are astonishing and heartbreaking numbers of people.

West Virginia has done well through the COVID-19 pandemic. We have the eighth lowest number of cases since the beginning of the pandemic and the ninth-lowest number of deaths from COVID-19.

How has this happened?

Largely because of our citizens and their commitment to protecting each other, staying together and caring for one another.

When COVID-19 started to spread in the United States, West Virginia’s Governor implemented an executive order to instruct our citizens stay at home. This is what the author Tomas Pueyo calls “the hammer.” After ensuring the initial spread of COVID-19 did not create a surge to overwhelm our healthcare systems, we moved to a different strategy. One that enabled West Virginia to reopen. This is the phase that Pueyo calls “the dance.”

To successfully reopen the state, we knew that widespread testing would be foundational in controlling COVID-19 spread.

Why is this?

It is clear that a very small number of people infected with COVID-19 spreads the virus to a majority of others. To be exact, as few as 5 to 9 percent of infected individuals infect 80 percent of all others. These people are referred to as “superspreaders.” What is most concerning about these individuals is that they often spread the virus to others while being unaware they are infected.

That is right. In the 2 1/2 days before experiencing infectious symptoms, these individuals are capable of infecting others.

This means to identify these individuals, they need to get tested. One of the reasons we have so many community testing events in places that are showing more COVID-19 spread is because we want to identify those infected people who have no symptoms.

Aggressive testing of West Virginia citizens is a cornerstone of our strategy for controlling COVID-19 spread in West Virginia. This is the key issue that caused the Governor to challenge all of us to refine our metric approach for opening schools in the state.

Initially, we solely used an incidence/infection rate for delineating the spread of COVID-19 in West Virginia, as has been championed by the Harvard Global Health Institute. Of note, incidence/infection rates in the Harvard model rely on a seven-day rolling average of new daily positive tests corrected to a population of 100,000.

There is no accounting for the total number of COVID-19 tests completed to generate the number of daily positive tests. The Harvard model also counts any positive test, both those derived from community and from congregate settings. Initially, we decided to count only tests reflecting true community spread, as opposed to counting new daily tests from both community and congregate sources. As an example, large congregate outbreaks in isolated settings, like the Huttonsville prison outbreak in Randolph county, complicate the assessment of the amount of real community spread.

One of the limitations we realized is that citizens of counties with high incidence/infection rates were disincentivized to test. Fewer daily positives tests equated to reduced incidence/infection rates. Thus, over time, only those with symptoms were getting tested.

As a result, our Rt values, the reproduction number for COVID-19, rose (we were worst in the country for almost a week), our death rates increased and we were seeing more widespread COVID-19 outbreaks in the state. Additionally, our number of tests declined.

We then made a critical adjustment in our model.

We added another metric - the percent positive rate. This rate assesses the daily new COVID-19 positive tests as a ratio of all tests taken in this same 24-hour period.

We followed guidance from other public health guidance from the Centers for Disease Control, the World Health Organization and the Harvard Global Health Institute to define the minimal rate to allow school openings as being less than five percent positive rate.

In addition, we settled on a five-color, coded system to reflect the county status of COVID-19 spread in West Virginia. To open schools, counties needed to be in the Gold, Yellow or Green categories.

In this current approach, the better of the following metrics are used – all as seven- or 14-day rolling averages:

• Gold - incidence/infection rate 10-15 daily new cases/100,000 population or a percent positive rate of less than four percent.
• Yellow - incidence/infection rate 3-10 new cases/100,000 population or percent positive rate of less than 4 percent.
• Green - incidence/infection rate 0-3 new cases/100,000 population or percent positive rate of less than three percent.

This new addition adds a clear incentive for our citizens to test more broadly, and since we have made this change, we have nearly doubled the number of tests done in West Virginia on a daily basis. Our goal is to increase to 8,000 tests per day (we were stuck on approximately 3,000 per day).

Since initiating this approach, we have seen our Rt values move from worst in the county to the second-best today. In addition, the death rate of West Virginia residents appears to be slowing, and our daily number of tests is rising substantially.

It is important to note that our ultimate goal is to protect West Virginia’s citizens from COVID-19 infection and to reduce surge spread in the state and not to just find a system that can open all the schools. The best protection for children, teachers and staff in schools is to control COVID-19 spread in the schools’ communities.

That is what we are working to do.

As things progress, we will continue to focus on protecting the health of our citizens and evaluate our assessment system. I know it is a challenging time, and we are all tired. Yet, the single key contributor to our outcomes is that our state has stayed together. And, that requires trust.

I hope this somewhat lengthy communication helps explain why we have taken the steps we have taken to date.

There is no playbook or blueprint to follow, and we’re all human.

Thank you, West Virginia, for caring for each other.

Keep encouraging those who haven’t been tested to do so.

No matter the color code of your county, please continue to follow known health and safety guidance:

• Wear your mask.
• Stay distanced.
• Wash your hands.
• Avoid crowds, closed indoor spaces and constant contact with those who do not live within your home.

We are a beacon for others. Because of each one of you.